Member Grievance Form

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Contact Information

If you need help or have questions, please call us.

Medi-Cal and Healthy Workers HMO Members

Call 1(415) 547-7800, 1(800) 288-5555 (toll-free), or 711 (TTY),
Monday–Friday, 8:00am–5:00pm.

SFHP Care Plus Members

Call 1(415) 539-2273, 1(833) 530-7327 (toll-free), or 711 (TTY).
We are open 8:00am–8:00pm, seven days a week from October through March,
closed on Saturdays and Sundays from April through September.

Member ID:	11-digit SFHP Member ID number.
Name:	Required Please enter only text.
Email Address:	Please provide your phone number and/or email address so that we can contact you regarding this issue. Required Please enter valid Email Id.
Phone Number:	Required Please enter valid phone number.
Grievance Description: Please describe the problem in detail, what has been done so far, if anything, and describe what you would like someone to do to solve the problem.	Required
Urgency:	Please select if you have a problem that needs medical attention in the next three days, or if you are in severe pain.
	Required
	Please describe why waiting more than three days for an answer from us will hurt your health (use and attach additional sheets if necessary). You might qualify for an expedited grievance or appeal.

Important Message From the Department of Managed Health Care

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1(415) 547-7800 or 1(800) 288-5555 and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number 1(888) 466-2219 and a TTY line 1(877) 688-9891 for the hearing and speech impaired. The department’s internet website www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online.